Question of the Week # 458

458) A 65-year-old man is brought to the emergency department after having two large bowel movements over the past hour that consisted of bright red blood and no stool in the past 3 hours. He denies any abdominal pain or nausea, but does recall having crampy abdominal discomfort after eating over the last several days. His past medical history is significant for hypertension and diabetes and his medications include lisinopril, metoprolol and metformin. He had a colonoscopy at the age of 55 which was unremarkable. On presentation, his temperature is 37.0°C (98.6°F), blood pressure is 80/60 mm Hg, and pulse is 110/min. His abdomen is soft and nontender. There is no guarding or rebound tenderness. There is fresh red blood in the rectum, but there are no palpable masses. Intravenous fluid boluses are started. Which of the following is the most appropriate next step in the management of this patient?
A. Perform upper gastrointestinal endoscopy
B. Order a CT scan of the abdomen
C. Order a nuclear bleeding scan of the colon
D. Perform a colonoscopy
E. Perform nasogastric aspiration

14 Responses

  1. Where r the answers to these questions

  2. answer is A, endoscopy, cant to colonoscopy cause he is actively bleeding and u wont be able to see any thing. NG suction does not yeild accurate result and it will waste time.CT scan does not show the location of the bleed.and nuclear bleeding scan is done after the endoscopy fails to see the bleed.I hope my reasoning is correct.

  3. D

  4. E is the answer. First of all rule out the upper GI bleed

  5. Lower GI Bleeds have always been confusing for me. I want to do a colonoscopy because his age, past history and current presentation all point to ischemic colitis. But his bp is 80/60 which makes me wonder is he having a massive upper gi bleed? Plus then there is the protocol which says rule out upper gi bleed first. And I keep reading in different resources do ng tube or do endoscopy. So confusing!!! Dr Red. I would really appreciate your comments on this. Thank you very much.

    • Correct Answer is E.
      Acute lower gastrointestinal (GI) bleeding accounts for 20% of all cases of GI bleeding. The evaluation of massive or hemodynamically unstable lower GI bleeding always includes a nasogastric (NG) aspiration, since 11% of patients will have an upper cause of their bleeding. After a copious, non-bloody, bilious fluid has been obtained from NG aspirate, the evaluation continues with a lower endoscopy. However, if the aspirate is both non-bloody and non-bilious then the location remains undetermined as nasogastric aspiration may miss bleeding between a closed pylorus and the ligament of Treitz.
      If NG aspirate is positive for blood or if bilious fluid cannot be obtained the best next step is to perform an upper endoscopy.
      In the setting of massive GI Bleeding , nasogastric aspiration with saline lavage is also used to assess the degree of bleeding because a persistently bloody aspirate despite saline lavage may help the physician anticipate the patient’s need for blood transfusion, urgent EGD, and ICU admission

      Key point : If no blood is returned and bile is identified on nasogastric aspiration, an upper GI source is much less likely and the workup can focus on the large bowel. If the aspirate returns bloody, then an upper endoscopy (Option A) is the next step in management.

      Answer B:
      There is very limited role for an abdominal CT in the evaluation of an acute GI bleeding.

      Answer C:
      A nuclear bleeding scan is (typically) used in bleeding whereby the source cannot be discovered with other, more conventional methods. It is more sensitive to detect low-level bleeding than either colonoscopy or angiography.

      Answer D:
      Colonoscopy is one of two diagnostic tools of choice used to evaluate acute lower GI bleeding. Several studies have demonstrated that colonoscopy identifies definitive bleeding sites in more than 70% of patients. Colonoscopy may be performed urgently or electively, depending on the patient’s hemodynamic status and risk-stratification criteria. Advantages of colonoscopy include direct visualization, access for tissue biopsy and direct bleeding control. In an emergent setting, however, colonoscopy is of limited value due to presence of stools in the colon and in the case of massive bleeding – poor visibility. If bleeding is minimal and patient is hemodynamically stable, Colonoscopy may be performed here electively.

      • Thank you very much for the explanation

      • So, just to make sure – since a non-bilious, non-bloody NG aspirate would necessitate an upper GI endoscopy, it is better to just go ahead with the upper GI endoscopy in the first place to obviate the need for 2 separate tests and thus save time. Is that the correct conclusion?

      • Hi Rohini…No, NG aspiration is the first step. There was an error in the answer. Please check the explanation above. Thank you.

      • Alright. Thank you very much. 🙂

      • Thank you also for rewriting the explanation. Got a lot more clarity in the subject.

    • it can be confusing, but its quite simple really, the key is the timing, the question says that there were 2 large volumes of blood passage in three hours, during that time blood from the upper GI and rectum are indistinguishable ie you don’t know if its from the gullet or the colon. if there is an upper GI bleed from the oesophagus to the ligament of treitz in small bowel the NG is a quick and easy way to find this and then do endoscopy to locate the site of bleeding and treat, and its a sensitive test. if its negative then proceed with colonoscopy.

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